病例报告（英文）

Casepresentation96.09.04 Intern Intern 胡學錦胡學錦Personalprofilen nName:吳O民 n nGender:malen nAge:46 years oldn nChart number:16762291n nArrival date at ED:96/08/20n nTime:04:15 amInjurymechanismn nSuffered from a traffic accident with drunken state this morning(04:00am)Suspect drunken drivingn n現場生命現象:drowsy and irritable(E3V3M4)n nCC:Alcoholism with Traffic accident Pre-hospitalevaluationandmanagementn nSent to KMUH ER by 119n nHead:ILOC(?),dizziness(?),headache(?),nausea/vomiting(?),amnesia(?),vertigo(?)laceration wound over rt upper eyelid and earlobe n nNeck:pain,stiff,soreness(?)n nChest:pain,dyspnea(?)n nAbdomen:pain,discomfort(?)n nLimbs and skin:abrasion wound over bil.kneeAMPLEhistoryn nAllergies:unknownn nMedication:unknownn nPast illness:n nDM:(?)DM:(?)n nHTN:(?)HTN:(?)n nOther systemic diseases(?Other systemic diseases(?)n nOperation history(?)Operation history(?)n nLast Meal:(?)Initialevaluation(KMUH)A(airway)/B(breathing):l lCollar fixation:(+)l lAirway:speech:(?)respiration:smoothl lairway obstruction sign(-)l l foreign body in the mouth(-)l lTrachea l lBreathing sound:clearl lC(circulation):l lRate:brachial a.,carotid a.,femoral a.,dorsalis pedis a.l lCuff BP:105/45 mmHgl lSkin condition:appearance,temperature,humidityD(disable):l l GCS:GCS:E2V2M5E2V2M5l l Pupil response:Pupil response:odod:2 mm:2 mm osos:2 mm:2 mm E(exposure):l labrasion wound over nose and abrasion wound over nose and bilbil.maxillary.maxillary area,area,l llaceration wound over laceration wound over rtrt.upper eyelid(2 cm).upper eyelid(2 cm)and earlobe(1 cm)and earlobe(1 cm)l labrasion wound over abrasion wound over bilbil.knee.kneeSecondaryevaluation(KMUHER)n nChest X-ray AP&lateral view n nCervical spine X-ray AP&lateral viewn nPelvis X-ray APn nBrain CT without contrast(due to drowsy consciousness and irritable state,brain CT was hold for safety concern)Labdata(96/08/20)Labdata(96/08/20)Chestx-rayCervicalspineX-rayPelvisX-rayPlann nClose observation with plaining brain CT studyAt16:05n nConsciousness:coma GCS:E1V1M1 Pupil size:R/L:3.5/2.0 with negative light reflex BP:150/78 mmHg PR:95/bpm.n nHe was sent for emeregnt brain CTn nEmergent endotracheal intubation after Citosol sedation with paralytics(Genso)Tentativediagnosisn nTraumatic ICH and SDH with mass effect and midline shiftn nAlcoholism additionn nr/o C-spine injuryn nLeft ear lobe laceration(1cm)n nFacial laceration(2 cm)n nAbrasion wound over bilateral kneesn nUnder the impression of traumatic ICH and SDH with mass effect and midline shift,N/S was consult and he was sent to OR for emergent right craniectomy,SDH&ICH removal and ICH monitor insertion.n nThen,he was admitted to 7ENI-31 for further therapy.PostOperationn n08/21,GCS:E1 VE M2ICP was controled during 1217mmHg,and glycerol was used.Fever up to 39,Sputum(+)were noted.Antibiotics:Cefazolin 1g iv q8h day 2 Gentamicinn nDuring 08/2208/24,spiking fever up to 40 was noted.n n08/25:The sputum culture collected on 8/22 showed Pseudomonas aeruginosa,and antibiotics shifted to Tazocin 2 vial q8h.n nDuring 08/2608/28,persisted mild fever up to 39 was noted.Follow up brain CT on 8/28:Follow up brain CT on 8/28:(1)Rt contusion hemorrhage with resolution and(1)Rt contusion hemorrhage with resolution and perifocal edema perifocal edema(2)previous left EDH had no enlargement(2)previous left EDH had no enlargementn nRemove ICP monitor on 08/28n n08/29:fever subsided,remove endotracheal tuben n08/30:Transfer to NS wardQ:無法出無法出ICU之併發症之併發症?Q:留觀待醒過程是否易留觀待醒過程是否易delaydiagnosis?Q:酒後躁動患者是否酒後躁動患者是否sedation後去做後去做brainCT?Approachtoneuroimaginginchildren2007UpToDateApproachtoneuroimaginginchildren2007UpToDaten nSedationSedation Sedation is rarely required for CT Sedation is rarely required for CT examinations in children because most CT examinations in children because most CT examinations take only seconds or minutes to examinations take only seconds or minutes to perform,particularly when ultrafast helical/spiral perform,particularly when ultrafast helical/spiral or multidetector/multislice technology is used.or multidetector/multislice technology is used.n nHigh-resolution studies that require High-resolution studies that require immobilization immobilization to avoid motion artifact(eg,to avoid motion artifact(eg,temporal bone examination)temporal bone examination)are the exception.A are the exception.A newborn or young infant often can be examined newborn or young infant often can be examined during sleep(eg,after a feeding or at the usual during sleep(eg,after a feeding or at the usual nap-time).nap-time).Hepatictrauma:CTfindingsandconsiderationsbasedHepatictrauma:CTfindingsandconsiderationsbasedonourexperienceinemergencydiagnosticimagingonourexperienceinemergencydiagnosticimagingEuropeanJournalofRadiologyVol:50Issue:1,April,EuropeanJournalofRadiologyVol:50Issue:1,April,2004p:59-662004p:59-66n nIn the case of non cooperative patients,presenting with neurological signs,sedation may be required and also assisted ventilation eventually,with continuous monitoring of cardiac and respiratory parameters.UseofIntravenousMethohexitalasaSedativeinPediatricUseofIntravenousMethohexitalasaSedativeinPediatricEmergencyDepartmentsEmergencyDepartmentsHananSedik,MDHananSedik,MD Arch Pediatr Adolesc Med.Arch Pediatr Adolesc Med.2001;155:665-6682001;155:665-668n nMethohexitalMethohexital has been used in adult emergency has been used in adult emergency departments and has been found to produce departments and has been found to produce rapid and rapid and brief sedationbrief sedation,especially for orthopedic procedures.,especially for orthopedic procedures.n nLerman et al studied 76 adult patients in a prospective Lerman et al studied 76 adult patients in a prospective observational study where IV methohexital had been observational study where IV methohexital had been used for a variety of procedures,and concluded that it used for a variety of procedures,and concluded that it caused clinically insignificant changes in caused clinically insignificant changes in hemodynamics hemodynamics and oxygenationand oxygenation.Although.Although respiratory depressionrespiratory depression did did occur,if significant it was brief and easily managed.occur,if significant it was brief and easily managed.n nZink et al reported a consecutive case series of 102 Zink et al reported a consecutive case series of 102 patients(including 10 patients younger than 10 years)patients(including 10 patients younger than 10 years)who received IV methohexital for various procedures.who received IV methohexital for various procedures.The authors concluded that The authors concluded that methohexital is safe and methohexital is safe and effectiveeffective in selected emergency department patients.in selected emergency department patients.Current conditionn nAdmission to 7B 27-1Admission to 7B 27-1n nGCS:E2 V2 M3GCS:E2 V2 M3n nBP:109/78 mmHgBP:109/78 mmHgn nPupil:R 2.5mm L 2.5mm,bilateral prompt reflex Pupil:R 2.5mm L 2.5mm,bilateral prompt reflex n n MP R L MP R L upper limb 2 1 upper limb 2 1 lower limb 2 2 lower limb 2 2 n nPlan:Plan:1.keep Saxizon 100mg iv q8h second day due to 1.keep Saxizon 100mg iv q8h second day due to bilateral bronchus wheezingbilateral bronchus wheezing2.Antibiotics:Tazocin 2 vial iv q8h day 92.Antibiotics:Tazocin 2 vial iv q8h day 93.Consult rehabilitation department3.Consult rehabilitation departmentThanks for attentionLermanB,YoshidaD,LevittMA.AprospectiveLermanB,YoshidaD,LevittMA.Aprospectiveevaluationofthesafetyandefficacyofmethohexitalinevaluationofthesafetyandefficacyofmethohexitalintheemergencydepartment.theemergencydepartment.Am J Emerg Med.Am J Emerg Med.1996;14:351-354.1996;14:351-354.n nMTX caused clinically insignificant changes in hemodynamics or oxygenation,although respiratory depression did occur;significant respiratory depression was brief and easily managed.MTX provided rapid and excellent levels of sedation with little or no patient recall or pain.